Issues of life and limb

We use our limbs in just about every activity of daily living; that is why pain or injury to our hands and feet are so debilitating. TAN SU YEN reports on the latest advances in hand and foot surgery

'OUR hands tell the story of our lives. The hands of a parent hold a newborn within minutes of its birth; those same hands nurture that infant into adulthood. We work with our hands, we eat with our hands, we talk with our hands, we raise our fists in triumph, or turn them against another in anger; we put our hands together in prayer.'

Dr Looi Kok-Poh routinely launches into lectures on hand and wrist surgery by reflecting on our hands as a metaphor for our lives, and with good reason. A consultant hand, wrist and reconstructive micro surgeon with Pacific Hand, Wrist and Microsurgical Centre, Dr Looi has a keen interest in the training of
medical professionals in hand and wrist surgery. This he does through his role as a visiting consultant at the National University Hospital of Singapore and in his role as chairman of the Wrist Interest Group.

Says Dr Looi: 'Our hands are a very intricate part of the body. Not only are the structures in our hands very small, the functions are very complex. Therefore, hand surgeons need to be able to work with bigger structures like the bones and finer things like micro blood vessels.'

As such, hand surgery has evolved into a clinical sub-specialty that combines orthopaedics, plastic surgery and microsurgical techniques. One area of the hand that offers particular challenges to hand surgeons is the wrist, given the concentration of tendons, bones and nerves in a narrow, confined space. Says Dr Looi who trained in wrist surgery at the world famous Mayo Clinic in Rochester, Minnesota: 'The wrist is a grossly neglected area in the orthopaedic field. Everybody has some sort of wrist pain but no one seems to know what is going on. Fortunately, in the last 20 years the understanding of the wrist has improved tremendously.'

The Pacific Hand, Wrist and Microsurgical Centre provides comprehensive care for a wide range of hand, wrist and upper limb conditions, including the following commonly seen problems:

DeQuervain's Syndrome
This condition is characterised by pain on the thumb side of the wrist and is related to the excessive use of the thumb. DeQuervain's, which is also known as washerwoman's syndrome, used to be caused by manual work. In recent years, De Quervain's has been linked to the use of computer keyboards, making it part of a group of conditions described as Repetitive Strain Injury or RSI.

In addition to work related De Quervain's, a new patient profile seems to be emerging. Says Dr Looi: 'Many DeQuervain's patients I now see are first-time mothers who are over zealous in carrying their baby and over-obsessive when breast feeding. Some mothers don't know how to relax their hands when they breast feed a child and, therefore, they develop an overuse syndrome where the tendon gets stuck at this part of the wrist.'

The first step in managing DeQuervain's involves getting the patient to stop the offending activity so as to prevent further aggravation. Medication may be prescribed as a follow-up measure and the patient may be given an injection into the tendon to ease the inflammation pain. In severe cases of DeQuervain's, the tendon may need to be surgically released to relieve symptoms.

Trigger finger
Make a fist and then relax your hand by straightening out your fingers and thumbs. If the movement of your digits is smooth and continuous, you have nothing to worry about. If a finger or thumb gets stuck in a bent or flexed position as if poised to pull a trigger, you may be developing a condition known as a trigger finger.

Trigger finger comes about when a nodule develops in one of the tendons of our hands obstructing normal tendon movement. These tendons function like ropes that connect the muscles of the forearm to the bones in our fingers and thumb.

Musicians like jazz drummers and vibraphonists are particularly susceptible to trigger finger, which is related to gripping actions that are repetitive, intense and prolonged.

Treatment involves resting the hand and avoiding repetitive movements. According to Dr Looi, 75 per cent of patients with early stage trigger finger are cured with steroid injections in the palm; however, recurrences are common.

'With most patients, the offending activity is required for life as it is their vocation, so it is a question of managing recurrences, with surgery if necessary.'

Basal joint instability and scaphoid fractures
The basal joint, which is located at the base of the thumb, undergoes a tremendous amount of stress as the thumb does most of the work every time we move our hands, and we move our hands thousands of times in an average day.

When the cartilage at the basal joint wears off due to wear and tear, the joint becomes flattened and painful. Explaining the occurrence of basal joint instability, Dr Looi says: 'People have different tolerance levels. Some people develop joint instability and arthritis after decades at a job where they use their hands extensively. Others may develop these problems acutely. One such example would be a golfer who persists in driving 200 to 300 balls in the one session when the norm is 75 to 90 balls.' Breaking a fall with an outstretched hand also leads to wrist injuries and joint instability. In its more severe forms, joint instability can make daily activities painful; sometimes the pain persists even when the patient is at rest or asleep.

Where a wrist fracture occurs, Dr Looi points out that 87 per cent of the time it is the scaphoid bone, a cashew nut-shaped structure at the base of the thumb, that is fractured. The conventional treatment for a scaphoid fracture is to wear a cast for 10 to 12 weeks. The latest treatment for scaphoid fractures is the percutaneous screw fixation, which entails inserting a screw through the scaphoid so as to hold it firmly in place until the fracture heals. Patient does not have to wear a cast and have complete freedom to pursue sedentary work in two to three weeks.

Carpal Tunnel Syndrome
Pain, numbness and a tingling sensation in the thumb and index and middle fingers - these are the symptoms of Carpal Tunnel Syndrome in which the median nerve that passes through the wrist becomes compressed and swells under pressure.

This condition is common among secretaries and in other occupations with prolonged keyboard use. Dr Looi points out that in recent years, senior citizens who pursue new hobbies like tai qi or golf with a passion are also prone to developing Carpal Tunnel Syndrome.

Minimal Invasive Surgery and Arthroscopy
The most significant development in the treatment of hand and wrist conditions in recent years has been the development of arthroscopy or the means to look into a joint. Arthro meaning 'joint' and scopy meaning 'look'. Employing micro cameras, fibre optic cables and fine instruments like a 2mm probe, arthroscopy is now used to diagnose and treat whole range of hand and wrist conditions from Carpal Tunnel Syndrome to scaphoid fractures with minimally invasive techniques.

Says Dr Looi: 'Arthroscopy has become the method of choice for hand surgeons to treat ligament injuries, fractures and to remove lose bodies in the wrist and finger joints with minimal risk. Not only has arthroscopy allowed us to look at the inside of the wrist first hand - as opposed to the interpretive messages from MRIs or CT scans in the past - we can also treat these conditions at the same time. This has revolutionised our whole approach to hand and wrist surgery.'

Treating painful bunions

AS foot conditions go, bunions are common and particularly troublesome for those who need to be appropriately shod for work or business. This hard, prominent bump that appears on the joint of the big toe can make walking difficult and painful, and lead to the misalignment of the other toes. Worse, for those who love fashionable footwear, bunions often mean giving up shoes with high heels and pointed toes. But what exactly are bunions? And do they only affect women?

Bunions occur when the bone nearest the big toe (the first metatarsal bone) is displaced inwards causing the big toe to move towards the smaller toes. This shift in the bones of the feet causes a bony prominence to form on the bunion joint at the side of the foot. Over time, the big toe may come to rest under the second toe or sometimes over it. Bunions can lead to redness, swelling and pain as Dr Yung Shing Wai, consultant orthopaedic foot surgeon, MD Specialist Healthcare, explains: 'Much of the pain is from the pressure on a small nerve that runs over the bump. Pain can also be caused by abnormal corns that may form on the inside of the big toe or even on the ball of the second toe.'

While more women who suffer from bunions are seeking treatment, Dr Yung is emphatic that the incidence of bunions has not changed. 'Anyone can get bunions, male or female, young or old. The patient who presents to the doctor is one who has a problem with the deformity, such as pain, numbness and difficulty in wearing shoes.' And contrary to common belief, wearing pointed high-heeled shoes doesn't cause bunions per se although it could aggravate the problem.

Says Dr Yung: 'There are people with perfectly formed feet who wear high heels for years without developing bunions.' In fact, bunions are caused by intrinsic factors such as the shape of the foot joints, the length of the toes, flattened arches or a tight calf muscle, also known as an Achilles tendon. For example, people with what is known as an Egyptian foot characterised by abnormally long big toe or a Greek foot distinctive for its long second toe may be predisposed to foot problems.

Most people with bunions learn to live with them by turning to accommodative footwear such as shoes or sandals with a wider toe box and low heels. However, patients with more severe or painful bunions may opt for corrective osteotomy, a surgical procedure in which a cut is made in the bone to correct a deformity. Many forms of corrective osteotomy are available ranging from the simple to the more complex in which screws and wires are required.

Says Dr Yung: 'There is no single operation that fits every type of bunion; surgical options have to be tailored to the foot deformity and the associated problems. Recurrences are often the result of choosing the wrong operation and trying to stretch the indications for a simple operation to address a severe deformity.'

Mild, uncomplicated bunions may be addressed by a relatively simple procedure known as a distal osteotomy, with a short downtime of six to eight weeks. A proximal osteotomy is recommended for severe bunions or those complicated with hypermobility or a looseness of the first foot bone or Metatarsal. A proximal osteotomy and fusion to address hypermobility involves an operation known as the Lapidus Procedure, in which the base of the metatarsal is fused with screws. Recovery takes about four months, including six weeks in a cast.

In recent years, the Scarf Osteotomy, a hybrid procedure, has been developed marrying the short recovery times of the Distal Osteotomy with the larger corrections afforded by a Proximal Osteotomy. Named after a carpentry joint, the Scarf reduces downtime dramatically to about four to six weeks, about half the time of even the simpler Distal osteotomies. Patients can bear their body weight immediately and can walk unaided albeit with a limp two weeks after surgery.

Bunions are often associated with lesser toe deformities such as hammer toes where the second toe contracts, resulting in a corn forming over its last joint. These deformities as well as other related conditions like flat feet should be corrected with the main bunion procedure.

Source: Business Times, 11 August 2006